|
REGLAN(METOCLOPRAMIDE 10MG/2ML
|
Facility
|
IP
|
$74.13
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
636T0056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.64 |
| Max. Negotiated Rate |
$71.16 |
| Rate for Payer: Aetna Commercial |
$57.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Cash Price |
$37.06
|
| Rate for Payer: Cigna Commercial |
$61.53
|
| Rate for Payer: First Health Commercial |
$70.42
|
| Rate for Payer: Humana Commercial |
$63.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.23
|
| Rate for Payer: Ohio Health Group HMO |
$55.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.98
|
| Rate for Payer: PHCS Commercial |
$71.16
|
| Rate for Payer: United Healthcare All Payer |
$65.23
|
|
|
REGLAN(METOCLOPRAMIDE 10MG/2ML
|
Facility
|
OP
|
$74.13
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
63600056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.64 |
| Max. Negotiated Rate |
$71.16 |
| Rate for Payer: Aetna Commercial |
$57.08
|
| Rate for Payer: Anthem Medicaid |
$25.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Cash Price |
$37.06
|
| Rate for Payer: Cigna Commercial |
$61.53
|
| Rate for Payer: First Health Commercial |
$70.42
|
| Rate for Payer: Humana Commercial |
$63.01
|
| Rate for Payer: Humana KY Medicaid |
$25.49
|
| Rate for Payer: Kentucky WC Medicaid |
$25.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.23
|
| Rate for Payer: Ohio Health Group HMO |
$55.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.98
|
| Rate for Payer: PHCS Commercial |
$71.16
|
| Rate for Payer: United Healthcare All Payer |
$65.23
|
|
|
REGLAN(METOCLOPRAMIDE 10MG/2ML
|
Professional
|
Both
|
$74.13
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
63600056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$74.13 |
| Rate for Payer: Aetna Commercial |
$1.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$74.13
|
| Rate for Payer: Cash Price |
$37.06
|
| Rate for Payer: Cash Price |
$37.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1.60
|
| Rate for Payer: Multiplan PHCS |
$44.48
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$51.89
|
| Rate for Payer: UHCCP Medicaid |
$25.95
|
|
|
REGLAN(METOCLOPRAMIDE 10MG/2ML
|
Facility
|
OP
|
$77.18
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
25002335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.03 |
| Max. Negotiated Rate |
$74.09 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Anthem Medicaid |
$26.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.20
|
| Rate for Payer: Cash Price |
$38.59
|
| Rate for Payer: Cigna Commercial |
$64.06
|
| Rate for Payer: First Health Commercial |
$73.32
|
| Rate for Payer: Humana Commercial |
$65.60
|
| Rate for Payer: Humana KY Medicaid |
$26.54
|
| Rate for Payer: Kentucky WC Medicaid |
$26.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.92
|
| Rate for Payer: Ohio Health Group HMO |
$57.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.93
|
| Rate for Payer: PHCS Commercial |
$74.09
|
| Rate for Payer: United Healthcare All Payer |
$67.92
|
|
|
REGLAN(METOCLOPRAMIDE 10MG/2ML
|
Facility
|
IP
|
$77.18
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
25002335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.03 |
| Max. Negotiated Rate |
$74.09 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.20
|
| Rate for Payer: Cash Price |
$38.59
|
| Rate for Payer: Cigna Commercial |
$64.06
|
| Rate for Payer: First Health Commercial |
$73.32
|
| Rate for Payer: Humana Commercial |
$65.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.92
|
| Rate for Payer: Ohio Health Group HMO |
$57.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.93
|
| Rate for Payer: PHCS Commercial |
$74.09
|
| Rate for Payer: United Healthcare All Payer |
$67.92
|
|
|
REGONOL PYRIDOSTIGMINE 10MG2ML
|
Facility
|
IP
|
$122.36
|
|
|
Service Code
|
NDC 781304072
|
| Hospital Charge Code |
25003401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$117.47 |
| Rate for Payer: Aetna Commercial |
$94.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.44
|
| Rate for Payer: Cash Price |
$61.18
|
| Rate for Payer: Cigna Commercial |
$101.56
|
| Rate for Payer: First Health Commercial |
$116.24
|
| Rate for Payer: Humana Commercial |
$104.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.68
|
| Rate for Payer: Ohio Health Group HMO |
$91.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.93
|
| Rate for Payer: PHCS Commercial |
$117.47
|
| Rate for Payer: United Healthcare All Payer |
$107.68
|
|
|
REGONOL PYRIDOSTIGMINE 10MG2ML
|
Facility
|
OP
|
$122.36
|
|
|
Service Code
|
NDC 781304072
|
| Hospital Charge Code |
25003401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$117.47 |
| Rate for Payer: Aetna Commercial |
$94.22
|
| Rate for Payer: Anthem Medicaid |
$42.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.44
|
| Rate for Payer: Cash Price |
$61.18
|
| Rate for Payer: Cigna Commercial |
$101.56
|
| Rate for Payer: First Health Commercial |
$116.24
|
| Rate for Payer: Humana Commercial |
$104.01
|
| Rate for Payer: Humana KY Medicaid |
$42.08
|
| Rate for Payer: Kentucky WC Medicaid |
$42.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.68
|
| Rate for Payer: Ohio Health Group HMO |
$91.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.93
|
| Rate for Payer: PHCS Commercial |
$117.47
|
| Rate for Payer: United Healthcare All Payer |
$107.68
|
|
|
REGRANEX (BECAPLERMIN) 15 GRAM
|
Facility
|
IP
|
$140.98
|
|
|
Service Code
|
NDC 50484081015
|
| Hospital Charge Code |
25001297
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.33 |
| Max. Negotiated Rate |
$135.34 |
| Rate for Payer: Aetna Commercial |
$108.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.96
|
| Rate for Payer: Cash Price |
$70.49
|
| Rate for Payer: Cigna Commercial |
$117.01
|
| Rate for Payer: First Health Commercial |
$133.93
|
| Rate for Payer: Humana Commercial |
$119.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$115.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.06
|
| Rate for Payer: Ohio Health Group HMO |
$105.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.70
|
| Rate for Payer: PHCS Commercial |
$135.34
|
| Rate for Payer: United Healthcare All Payer |
$124.06
|
|
|
REGRANEX (BECAPLERMIN) 15 GRAM
|
Facility
|
OP
|
$140.98
|
|
|
Service Code
|
NDC 50484081015
|
| Hospital Charge Code |
25001297
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.33 |
| Max. Negotiated Rate |
$135.34 |
| Rate for Payer: Aetna Commercial |
$108.55
|
| Rate for Payer: Anthem Medicaid |
$48.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.96
|
| Rate for Payer: Cash Price |
$70.49
|
| Rate for Payer: Cigna Commercial |
$117.01
|
| Rate for Payer: First Health Commercial |
$133.93
|
| Rate for Payer: Humana Commercial |
$119.83
|
| Rate for Payer: Humana KY Medicaid |
$48.48
|
| Rate for Payer: Kentucky WC Medicaid |
$48.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$115.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$49.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.06
|
| Rate for Payer: Ohio Health Group HMO |
$105.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.70
|
| Rate for Payer: PHCS Commercial |
$135.34
|
| Rate for Payer: United Healthcare All Payer |
$124.06
|
|
|
REG THICK-SEVERE WRINKLE
|
Professional
|
Both
|
$600.00
|
|
| Hospital Charge Code |
22200671
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
|
|
REHABILITATION WITH CC/MCC
|
Facility
|
IP
|
$17,658.42
|
|
|
Service Code
|
MSDRG 945
|
| Min. Negotiated Rate |
$11,982.50 |
| Max. Negotiated Rate |
$17,658.42 |
| Rate for Payer: Anthem Medicaid |
$11,982.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$12,613.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$17,658.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$17,027.77
|
| Rate for Payer: Humana KY Medicaid |
$11,982.50
|
| Rate for Payer: Humana Medicare Advantage |
$12,613.16
|
| Rate for Payer: Kentucky WC Medicaid |
$12,102.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15,135.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,222.15
|
|
|
REHABILITATION WITHOUT CC/MCC
|
Facility
|
IP
|
$11,846.80
|
|
|
Service Code
|
MSDRG 946
|
| Min. Negotiated Rate |
$8,038.90 |
| Max. Negotiated Rate |
$11,846.80 |
| Rate for Payer: Anthem Medicaid |
$8,038.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,462.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,846.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,423.70
|
| Rate for Payer: Humana KY Medicaid |
$8,038.90
|
| Rate for Payer: Humana Medicare Advantage |
$8,462.00
|
| Rate for Payer: Kentucky WC Medicaid |
$8,119.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,154.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,199.68
|
|
|
REHAB ROOM RATE
|
Facility
|
IP
|
$2,287.00
|
|
| Hospital Charge Code |
11800001
|
|
Hospital Revenue Code
|
118
|
| Min. Negotiated Rate |
$297.31 |
| Max. Negotiated Rate |
$2,195.52 |
| Rate for Payer: Aetna Commercial |
$1,760.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,783.86
|
| Rate for Payer: Cash Price |
$1,143.50
|
| Rate for Payer: Cigna Commercial |
$1,898.21
|
| Rate for Payer: First Health Commercial |
$2,172.65
|
| Rate for Payer: Humana Commercial |
$1,943.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,875.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,687.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$686.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,012.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,715.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$457.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$297.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$708.97
|
| Rate for Payer: PHCS Commercial |
$2,195.52
|
| Rate for Payer: United Healthcare All Payer |
$2,012.56
|
|
|
REIMPLANT ARTERY EACH
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 35697
|
| Hospital Charge Code |
76101418
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.87 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$268.30
|
| Rate for Payer: Anthem Medicaid |
$122.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$256.07
|
| Rate for Payer: Healthspan PPO |
$263.79
|
| Rate for Payer: Humana Medicaid |
$122.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$205.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$125.33
|
| Rate for Payer: Molina Healthcare Passport |
$122.87
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$124.10
|
|
|
REIMPLANT ARTERY EACH
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS 35697
|
| Hospital Charge Code |
76101418
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem Medicaid |
$137.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Humana KY Medicaid |
$137.56
|
| Rate for Payer: Kentucky WC Medicaid |
$138.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$140.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
REIMPLANT ARTERY EACH
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS 35697
|
| Hospital Charge Code |
76101418
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
REIMPLANT ARTERY EACH(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 35697
|
| Hospital Charge Code |
761P1418
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.87 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$268.30
|
| Rate for Payer: Anthem Medicaid |
$122.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$256.07
|
| Rate for Payer: Healthspan PPO |
$263.79
|
| Rate for Payer: Humana Medicaid |
$122.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$205.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$125.33
|
| Rate for Payer: Molina Healthcare Passport |
$122.87
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$124.10
|
|
|
REIMPLANT RENAL ART W/SAPH VEI
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS 37799
|
| Hospital Charge Code |
76102890
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
REIMPLANT RENAL ART W/SAPH VEI
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 37799
|
| Hospital Charge Code |
76102890
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
|
|
REIMPLANT RENAL ART W/SAPH VEI
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS 37799
|
| Hospital Charge Code |
76102890
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$760.54 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem Medicaid |
$137.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.37
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Humana KY Medicaid |
$137.56
|
| Rate for Payer: Humana Medicare Advantage |
$543.24
|
| Rate for Payer: Kentucky WC Medicaid |
$138.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$140.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
REIMPLANT URETER IN BLADDER
|
Facility
|
OP
|
$1,230.00
|
|
|
Service Code
|
HCPCS 50785
|
| Hospital Charge Code |
76102812
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.90 |
| Max. Negotiated Rate |
$1,180.80 |
| Rate for Payer: Aetna Commercial |
$947.10
|
| Rate for Payer: Anthem Medicaid |
$423.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$959.40
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cigna Commercial |
$1,020.90
|
| Rate for Payer: First Health Commercial |
$1,168.50
|
| Rate for Payer: Humana Commercial |
$1,045.50
|
| Rate for Payer: Humana KY Medicaid |
$423.00
|
| Rate for Payer: Kentucky WC Medicaid |
$427.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,008.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$907.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$369.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$431.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,082.40
|
| Rate for Payer: Ohio Health Group HMO |
$922.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$246.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$159.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$381.30
|
| Rate for Payer: PHCS Commercial |
$1,180.80
|
| Rate for Payer: United Healthcare All Payer |
$1,082.40
|
|
|
REIMPLANT URETER IN BLADDER
|
Professional
|
Both
|
$1,230.00
|
|
|
Service Code
|
HCPCS 50785
|
| Hospital Charge Code |
76102812
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$430.50 |
| Max. Negotiated Rate |
$1,968.83 |
| Rate for Payer: Aetna Commercial |
$1,968.83
|
| Rate for Payer: Anthem Medicaid |
$1,019.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,230.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cigna Commercial |
$1,753.74
|
| Rate for Payer: Healthspan PPO |
$1,574.26
|
| Rate for Payer: Humana Medicaid |
$1,019.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,650.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,039.65
|
| Rate for Payer: Molina Healthcare Passport |
$1,019.26
|
| Rate for Payer: Multiplan PHCS |
$738.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$861.00
|
| Rate for Payer: UHCCP Medicaid |
$430.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,029.45
|
|
|
REIMPLANT URETER IN BLADDER
|
Professional
|
Both
|
$2,750.00
|
|
|
Service Code
|
HCPCS 50780
|
| Hospital Charge Code |
76102057
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$907.44 |
| Max. Negotiated Rate |
$2,750.00 |
| Rate for Payer: Aetna Commercial |
$1,780.98
|
| Rate for Payer: Anthem Medicaid |
$907.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,750.00
|
| Rate for Payer: Cash Price |
$1,375.00
|
| Rate for Payer: Cash Price |
$1,375.00
|
| Rate for Payer: Cigna Commercial |
$1,592.01
|
| Rate for Payer: Healthspan PPO |
$1,424.05
|
| Rate for Payer: Humana Medicaid |
$907.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,503.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$925.59
|
| Rate for Payer: Molina Healthcare Passport |
$907.44
|
| Rate for Payer: Multiplan PHCS |
$1,650.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,925.00
|
| Rate for Payer: UHCCP Medicaid |
$962.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$916.51
|
|
|
REIMPLANT URETER IN BLADDER
|
Facility
|
OP
|
$2,750.00
|
|
|
Service Code
|
HCPCS 50780
|
| Hospital Charge Code |
76102057
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$357.50 |
| Max. Negotiated Rate |
$2,640.00 |
| Rate for Payer: Aetna Commercial |
$2,117.50
|
| Rate for Payer: Anthem Medicaid |
$945.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,145.00
|
| Rate for Payer: Cash Price |
$1,375.00
|
| Rate for Payer: Cigna Commercial |
$2,282.50
|
| Rate for Payer: First Health Commercial |
$2,612.50
|
| Rate for Payer: Humana Commercial |
$2,337.50
|
| Rate for Payer: Humana KY Medicaid |
$945.72
|
| Rate for Payer: Kentucky WC Medicaid |
$955.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,255.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,029.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$825.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$964.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,420.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,062.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$357.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$852.50
|
| Rate for Payer: PHCS Commercial |
$2,640.00
|
| Rate for Payer: United Healthcare All Payer |
$2,420.00
|
|
|
REIMPLANT URETER IN BLADDER
|
Facility
|
IP
|
$2,750.00
|
|
|
Service Code
|
HCPCS 50780
|
| Hospital Charge Code |
76102057
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$357.50 |
| Max. Negotiated Rate |
$2,640.00 |
| Rate for Payer: Aetna Commercial |
$2,117.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,145.00
|
| Rate for Payer: Cash Price |
$1,375.00
|
| Rate for Payer: Cigna Commercial |
$2,282.50
|
| Rate for Payer: First Health Commercial |
$2,612.50
|
| Rate for Payer: Humana Commercial |
$2,337.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,255.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,029.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$825.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,420.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,062.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$357.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$852.50
|
| Rate for Payer: PHCS Commercial |
$2,640.00
|
| Rate for Payer: United Healthcare All Payer |
$2,420.00
|
|
